AHIP Medicare Prescription Drug Plan Guide

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Worksheet

Fill in your information, then print out this page for your records. This will be helpful when you prepare to sign up for a plan.

IMPORTANT!

1) The information in the worksheet is completely private and will not be stored. Its only purpose is to help you understand your own priorities.
2) None of the fields are required. If you don't know an answer, feel free to leave it blank.

Step 1: Figure Out What is Best for You

As with many consumer decisions, you may need to make tradeoffs to get a plan that provides you with the best overall value. Answering the questions below will help you set your own priorities and make decisions that are right for you.

The Three C's: Coverage, Cost, and Convenience

Look over the questions under the coverage, cost, and convenience headings below. Check ONE item under each question based on how important it is to you.

1. Coverage
How important is it for my exact prescription drugs to be on the formulary?

	Very important
	Somewhat important (I am willing to discuss alternative drugs with my doctor.)
	Not at all important (I will ask my doctor for alternative drugs if they are available.)

How important is it that I have prescription drug coverage in the coverage gap?

	Very important (I have high drug costs.)
	Somewhat important
	Not at all important (I do not expect to reach the coverage gap this year.)

How important is it to have additional benefits in my health plan that go beyond Original Medicare (e.g., a cap on what I pay out of pocket for hospital and doctor services)?

	Very important
	Somewhat important
	Not at all important

How important is it that I have prescription drug coverage for drugs not covered by Medicare (known as excluded drugs)?

	Very important
	Somewhat important
	Not at all important

2. Cost
To pay for my prescription drugs, I prefer to pay most of my costs:

	Through a predictable but higher monthly premium, combined with a lower coinsurance or copay at the point that I see a doctor or have a prescription filled
	Through a higher coinsurance or copay at the point that I see a doctor or have a prescription filled, combined with a lower monthly premium

	A predictable but higher monthly premium combined with lower coinsurance or copays may be best if you have high medical or drug costs.
	A higher coinsurance or copay combined with a lower monthly premium may be best if you need fewer prescriptions and doctor or hospital visits.

How important is the total amount that I must pay each year for prescription drugs?

	Very important
	Somewhat important
	Not at all important

What portion of my total monthly health plan premium am I willing to/able to pay for prescription drugs?

	$0 per month (I do not want to pay a portion of my premium for prescription drugs.)
	$1 – $15 per month
	$16 – $30 per month
	More than $30 per month

What level of total monthly Medicare health plan premium (including hospital, doctor, and prescription drugs) am I willing to pay?

	$0 - $25 per month
	$26 - $50 per month
	$51 - $100 per month
	more than $100 per month

Would I prefer to pay a flat copay or a percentage coinsurance on each prescription?

	A flat copay (such as $10 or $20)
	A percentage coinsurance based on the price of the prescription drug

3. Convenience
How important is it that I keep my current doctor(s)?

	Very important (I am not willing to change doctor(s).)
	Somewhat important
	Not at all important (I am willing to change doctor(s).)

How important is it that I keep my current hospital?

	Very important
	Somewhat important
	Not at all important

How important is it that I keep my same pharmacy?

	Very important (I am not willing to change my pharmacy.)
	Somewhat important
	Not at all important (I am willing to change my pharmacy.)

How important is it that I have access to network pharmacies in other cities and towns?

	Very important
	Somewhat important
	Not at all important

How important is it that I be able to get extended supplies of my medications (e.g., a 90-day supply) either from my local pharmacy or by mail order?

	Very important
	Somewhat important
	Not at all important

Step 2: Determine Your Priorities

I want to:

	Pay a higher monthly premium, but a lower copay or coinsurance on each prescription
	Pay a higher copay or coinsurance on each prescription, but a lower monthly premium

Check the four options that are MOST important to you and also the four that are LEAST important to you.

IMPORTANCE
MOST	LEAST

		Additional benefits beyond Original Medicare
		My exact drugs are on the formulary
		Coverage in the coverage gap
		Coverage for excluded drugs
		Total amount I must pay each year for prescriptions
		My monthly prescription drug premium
		Paying a flat copay on each drug instead of a percentage coinsurance
		Keeping my current doctor(s)
		Keeping my current hospital
		Keeping my same pharmacy
		Having access to network pharmacies when I travel
		Having access to extended supplies of my prescription drugs

Step 3: Plan Comparison Worksheet
ABOUT ME

Please check the boxes that apply to you:

	I am eligible for or enrolled in Medicare now. OR
	I will be eligible for Medicare in the coming year.
	I qualify for extra help for my Medicare prescription drug costs. OR
	I do not qualify for extra help for my Medicare prescription drug costs.

Name(s) of current health and prescription drug insurance. (If you are not certain, look at the card(s) you use when you go to the doctor and pharmacy.)

I currently spend $ per month OR $ per year on prescription drugs.


	If you do not know all your drugs and how much you spend, ask your pharmacy if it can give you this information. Ask for your drug history and costs for the last 12 months.

My doctors:

Additional benefits I need from my health plan:

What am I willing to/able to pay for my Medicare health plan drug benefit?

Monthly Combined Health Plan Premium (Doctor, Hospital, & Prescription Drugs)

	$0 – $25 per month
	$26 – $50 per month
	More than $100 per month

Prescription Drug Portion of My Monthly Health Plan Premium

	$0 per month
	$1 – $15 per month
	$16 – $30 per month
	More than $30 per month

Copay or Coinsurance

	Flat copay for each prescription
	Percentage coinsurance for each service or prescription, based on the price of the service or drug

My Other Priorities

My Pharmacy (Name):

My Medicare Health Plan Choices

For this section, you will need your red, white, and blue Medicare card, and any other current health insurance card you may have.

Go to medicare.gov to find information on the plans in your community. Click on the "Compare Medicare Prescription Drug Plans" link. From there, follow the instructions to find up to 4 prescription drug plans that suit your needs based on your coverage, cost, and convenience priorities. Record what you want or are able to pay and then how much you would pay with each of the plans in the spaces below.

IMPORTANT!

None of the fields below are required, so if you don't have all of the information, don't worry! You'll be able to print out the form and fill in the rest of it later.

	Plan 1	Plan 2	Plan 3	Plan 4
Medicare Health Plan Name
Monthly Combined Health Plan Premium	$	$	$	$
$ Copay or % Coinsurance

Is my pharmacy in the plan network?
Are my doctors in the network?
Is my hospital in the network?

Finally, type in the prescription drugs you are currently taking, and calculate the cost of a 30-day supply under each plan.

My Prescription Drugs

Plan 1

Plan 2

Plan 3

Plan 4

Cost for a 30-day Supply

Drug Name
Dosage
How Often

Drug Name
Dosage
How Often

Drug Name
Dosage
How Often

Drug Name
Dosage
How Often

Drug Name
Dosage
How Often

Drug Name
Dosage
How Often

Drug Name
Dosage
How Often

Drug Name
Dosage
How Often

Drug Name
Dosage
How Often

Drug Name
Dosage
How Often

Click the print button below to print out this page for your records. This will be helpful when you prepare to sign up for a plan.

Once you have printed this page, click on the ‘next' button to learn about “How to Enroll”.